New guidance to reduce epidurals and a target rate of 20% for C-Sections

New guidance being issued by the RCOG, the NCT and the RCM is urging to decrease C-Sections to a target of 20%, to decrease epidurals and to make Midwife Led Care the default for low risk women. The document is here

This guidance is controversial and goes against the position of NICE, the NHSLA, and the DH.

I've already posted this in the Childbirth section, but I do think this needs a wider audience, and to get this seen by as many people as possible and it was suggested I posted this here rather than AIBU. Original thread is here

I do think this is definitely a Women's Rights issue for a couple of reasons:

Firstly its the language being used in the document. Its extremely paternalistic. It talks about getting the GP to influence patients to make 'good choices'. (I've expanded on how I feel about this on the other thread) and is extremely patronising and almost about trying to get women to behave in the correct manner rather than doing whats in their best interests.

Secondly theres the conflict of interest this causes - if a midwife/doctor is under pressure to achieve a target of 20% how are they going to do this as well as put the needs of the woman first?

Then theres the issue of restricting women's choices and options; especially with regard to pain relief.

The RCM, RCOG & NCT document has caused so much concern amongst a number of campaigners that its lead to them to issuing a joint statement which sums up all the issues far better than I can.

I find the whole thing quite alarming and frightening. I don't appear to be alone if the other thread is anything to go by.

I know its all a bit of a read and apologies in advance, but this is important and doesn't seem to be being reported anywhere else, and I do think this needs to 'get out there' for discussion and debate.

I know. But I don't think it's idealogical to say that a large amount of childbirth IS natural rather than life threatening and dangerous and so aiming to reduce the amount of medicalisation involved is a sensible act to redress the balance if possible.

Sioda Excellent point.rosabud I think you make a very good point here too, which is why I think it's time for us to try to find a way forward that respects ALL choices.

I'm not suggesting that this is easy, but in my experience I have found that there are more people who choose maternal request CS and epidurals - while also supporting the rest of the spectrum of birth choices - and fewer people who choose (for example) homebirth or no medical intervention - while offering the same support for women making a different choice.

I've said this before, but two wrongs don't make a right. If there's too much intervention for some women, the answer is not to take that intervention away from everyone. Choice isn't a real choice if the choice is being made for you or if there is only a very limited menu available.

Rosabud None of that makes the kind of attitude I'm talking about excusable. Anyway, this thing about balance was surely always the wrong way to look at it. What was needed was for individual women to have the freedom to choose the options or the balance of options that suited them. On that level there's no balance to be found between having an epidural or not, or between formula feeding or not. The truth is feminism was influenced by New Age anti-rationalist stuff from the 1960's on. That led to Nature and instinct being exalted and identified with women, science/reason and technology being associated with men and therefore patriarchy. The goal was never to balance the two - it was to exalt one in opposition to the other. It's still happening- for example in your own beliefs about the links between instincts, behaviour and environments. They're not uncommon. Indeed they seem to sound like common sense to a lot of women. But they're fundamentally based on an ideology of how women should be, not any kind of evidence.

Rosabud - would you look at the statistics for maternal (and neonatal mortality) in rural African and other parts of the world where there is no intervention (or ante-natal care quite often) e.g. http://www.voanews.com/content/african-maternal-mortality-defies-global-trend-91537854/160268.html1 in 16 African women die during pregnancy and childbirth. Its even highher in placed like Afghanistan with a 1 in 8 lifetime chance of dying during pregnancy and childbirth (they have no contraception so lots of pregnancies too).

This is what can happen in places where there is little or no intervention available. I do not want to overmedicalise or force interventions upon women who do not want them, but actually obstetricians have saved a lot of women's lives in the UK. They get a hard time when they "over-intervene" but that is because they want to avoid these risks. It can be a really hard judgement call for them. I prefer them to err on the side of caution with mine and my babies lives.

The big difference between here and Africa is the medical care available.

I agree with Widow -- I think saying childbirth is natural and not dangerous is a bit ideological, in that it ignores the fact that it is only because of modern medicine and hygiene practices that birth has become so much safer.

This is true even for homebirths -- it's not like you're giving birth alone on a dirty floor with loads of ill people around in close quarters (as women used to). You will optimally have a midwife with you, your house will be clean and disinfected, your family is likely to be healthy and non-contagious.

I think it's fine for a woman to choose no interventions if that's what she wants, I just think this blanket hostility to 'medicalisation' is ideological and kind of ahistorical.

When DW was pregant with DS1, some 12 years ago, I was totally unprepared for the amount of 'brainwashing' and pressure that she was subjected to when we visited the hospital maternity unit. Whether it be over pain relief or breast feeding versus formula.

The NCT is just one axis of this pressure and I know several people who are midwives and keen on the NCT mind set. I just dont like their attitude. DW had what might be called an old fashioned male gynecologist specialist looking after her because of health issues and he was rather lovely. He put it simply as this.

'The idea is to come through this as easily as posisble with a healthy live baby'.

He was happy to go with whatever DW wanted. The problem was the midwife who on the day did everything she could to prevent DW having an epidural.

I know doctors and midwives have been in conflict over who 'controls' the birth process for well over a century. No one seem sto think the mother should be the person in control. I dont get it.

Let's compare our day to day lives to when home birthing was the norm and it become clear why we need more intervention. I worked full time during pregnancy, drove to most places, slumped in the couch eating junk food, had my shopping delivered, used a washing machine and tumble dryer for the laundry, tidying up involves a quick Hoover and polish. I was sent home 6 hours post delivery where i was then expected to resume normal life. We also are having our children much later. Compare this with the life of my great grandmother who had her child in the 40s when they also had a lying in period after the birth to ensure breast feeding was established and women could rest. However before she died she told me the NHS was the best thing to happen in her lifetime. She grew up in a poor area and people would pay a 'midwife' to attend the birth which was usually an older woman in the community. Still births where very common. We have come a long way to have obstetrics recognised as a genuine medical area and for better ante natal and birth care and it seems the NCT want to undo all this by rose tinting the past.

Some natural birth advocates seen to think you walk in to hospital and are tethered to a bed with an epidural. People shout at OBEM 'get off the bed' but we don't know how long a woman has been in labour or how much pain she's in or if she even has the strength left to walk around. If we all have the right to a home birth (and rightly so even though it's not for me) then we all have a right to go to a consultant led hospital unit and give birth with the level of pain relief we deem necessary. We should also have the right to opt for an ELCS.

what is wrong with advising MLU birth for low risk first timers HB for subsequent when that comes with much lower levels of

forceps birthEMCS

for mothers

and lower rates of neo-natal admission for infants?

surely HCPs should advise people to do the least risky things according to the evidence? then if people want to do different, they still can? As currently most assume hospital, they would no doubt be questioning this anyway.

at present the typical MLU/ HB woman is older, and gives birth to a larger baby - yet the rates of forceps/EMCS are still significantly lower. the high rate of EMCS is not solely a population feature.

one of the findings of the Birth Place study was that women go to hospital simply because that's what you do. At the moment 95% of women give birth in CLUs - even those that aren't high risk and don't, at outset, want epidurals.

Do the 95% who give birth in CLU have access to a MLU? Our nearest one is closing down. I gave birth twice in a CLU but my care was midwife led. I was given information about the MLU and decided, based on the information that a transfer to neo natal would take 45 minutes and that there where no facilities beyond basic resus, that no matter how small the risk to my baby I was not taking that chance. That is my choice.

While I can totally see how it may be more comfortable for women to give birth or at least go through a large part of labour at home, I am so not surprised that a hospital birth is a default choice for many. I get a strong feeling that home-birth movement is, sorry if I offend anyone, a largely middle and most likely upper-middle class notion.

Let us just for a moment consider the home of an average mother with a less-than-average family income. It is likely to be a small terrace or a flat, with little sound insulation from the neighbours. This mother may also have other children and nowhere to put them at home during the often rather long process of labour. A hospital may be a safe heaven in such situations where a woman can get some privacy.

My husband and I have a good income, but when I gave birth to my DS, we were living in a shoe-box terrace with a living room door that opened straight onto a busy street full of childrens' tourist parties and teenagers from the nearby college smoking fags and playing loud music from their cars. Homebirth? No thanks. I felt much more relaxed in the hospital.

Now that I have a bigger house with more privacy, I am considering a homebirth, but I will probably be advised against it as DS was born through a C-section.

FrillyMilly, I gave birth in a hospital, I assume this was a CLU. Like you, my care was entirely midwife-led. I did not see a clinician until it was evident that my labour was not going very smoothly after 48 hours of contractions and only 6 cm dialation.

i think there are huge issues relating to choice, information, and how women are treated in labour.

women are often told 'you will be have a VE/ sweep/ be induced/' without being treated like rational human beings with the power to decide for themselves. The words 'allow' and 'let' are used eg. 'we will allow you a birth pool' 'we will let you have an ELCS' - rather than 'we advise'

This is the main feminist aspect i find in maternity care. there are others - such as the poor value attached to midwifery as opposed to obstetrics (even on this thread - this guidance came from RCOGs also and yet people are sounding off against MWS not Obs !)

bear in mind a 'natural' delivery is something you are more likely to get with a skilled midwife present as opposed to a 'maternity attendant'. i always put 'natural' in brackets, as skilled midwives don't just pop out of the undergrowth - they need training and a situation that nurtures professional development.

'natural' isn't a supported choice when MWs become deskilled.

the way 'maternal satisfaction; is seen as irrelevant by policy makers - that is also a feminist issue. MLUs get high rates of maternal satisfaction. So do HBs. So do CLUs with higher MW:attendee ratios. 1:1 midwife care is a feminist issue.

Edgar, because other outcomes matter too. Because people place different values on different risks. Because the Birthplace study is flawed. Because risks have to be weighed against benefits. Because the Birthplace study doesn't include planned caesareans in low risk women. Because where differences in some risks and benefits are insignificant enough, it's not appropriate to advise one course of action over another.

As for why women choose hospital births- can you link to that analysis in the Birthplace study? The fact that many women may not be aware that HBs or MLUs are an option and that they treat hospitals as a default does not prove that they would choose HB or MLU if they were informed about them and given the choice.

Just because women state that they don't plan to get an epidural before they go into labour doesn't mean that they don't want the facility to be (at least theoretically...) available on site. Most women are sensible enough to realise that they are not going to know in advance just what pain relief they will want. Most are also sensible enough to realise that just being low risk to begin with is no guarantee that everthing will go smoothly, and they would prefer to be in a place with all the facilities possible available to them on site should things go wrong. That reasoning is exactly what women respond with when someone, in say the Childbirth forum here, suggests that they consider HB or MLU. It's easy to frame a question about birthplace choice in such a way that you get the answer - 'because doesn't everyone just go to hospital?' - but it would be misleading.

'This is the main feminist aspect i find in maternity care. there are others - such as the poor value attached to midwifery as opposed to obstetrics (even on this thread - this guidance came from RCOGs also and yet people are sounding off against MWS not Obs !)'

I attach a lower value to midwifery than obstetrics because I don't value or want midwifery led care for myself. It has nothing to do with the gender balance of either profession and nothing to do with feminism. I fully support access to midwifery for women who do value it. There is nothing inherently either feminist or patriarchal about either midwifery or obstetrics.

The reason people are sounding off more against MWs is because the record of the RCM on birth choices is appalling. This is the organisation which proposed to charge women for epidurals a few years ago. The RCOG's record is simply not as bad. There are also plenty of individual OB's who genuinely and publicly support birth choices - including maternal request caesareans and access to epidurals. I've never heard a midwife do so in public. For what it's worth though I complained equally vehemently to both organisations because in respect of this particular guidance they are both equally guilty AFAIC.

"Lacking, I did sort of feel that some on here were arguing for being hooked up straight away, that it is a choice to say no pain at all, c section on demand or whatever. And, of course, that is a valid choice"

an on demand C section is not pain free, not afterwards, not always during! I think most women who choose CSs do know this! You have made a decision about people's motivations and I think its quite innacurate. I don't know anyone who chose elective surgery to "have no pain". There are all kinds of motivations, there may be a percentage for whom it is about pain, but there are many many others

those who have rosey images of childbirth pre access to CSs, go look up some of the alternatives that were commonly practiced when CSs were not, like "sympysiotomy", and may I also remind you about Kiellands forceps! I'm sick of this camp thinking the alternative to CS would be a peaceful natural birth with live and undamaged mothers and babies!

I do aplogise, I did not mean to imply a c section is pain free at all (though I can see that my sentence does imply this), I was simply acknowledging that choosing to be pain free (ie pain relief - although even that isn't totally pain free) or choosing a c section on demand are, of course, all valid choices. I know that a c section is a major operation with a relatively long recovery period.

These posts have made me think and I do accept that it is a good thing that advances in healthcare, medical treatment and technology have made childbirth much much safer which is a very good thing. If you argue that homebirths are a middle class thing (which I'm not convinced) then doesn't that suggest that it is something more available to those who have more access to information and who may have more confidence to choose that alternative. This suggests that homebirths or natural births or resisting medical intervention is not really a choice for all women at the moment?

putting a cap on CSs isn't gonna make me more keen to have a home birth, tripleing the size of my flat and sound proofing it might! whatcha gonna do give everyone nice big detatched houses to give birth in?

Maybe we need to be concentrating on the x% who opt for CLU having a better, pleasant and natural environment, and more midwives in situ for 1-1 care.

As one of the 5% who medically needed to give birth in a CLU I tend to find we're a bit forgotten in these debates - we don't have the choice, we do have substantial risks - but that doesn't mean we can't be supported toward a more 'natural' birth in a better environment!